STARZ Neonatal AKI Risk Stratification Cut-off Scores for Severe AKI and Need for Dialysis in Neonates Sidharth Kumar Sethi, Rupesh Raina, Sanjay Wazir, Gopal Agrawal, Ananya Vadhera, Nikhil Nair, Kritika Soni, Abhishek Tibrewal, Naveen Bajaj, Naveen Parkash Gupta, Shishir Mirgunde, Jagdish Sahoo, Binesh Balachandran, Kamran Afzal, Anubha Shrivastava, Jyoti Bagla, Sushma Krishnegowda, Ananth Konapur Kidney International Reports, 2022 IntroductionNeonatal acute kidney injury (AKI) is a significant pathology associated with higher mortality rates, longer neonatal intensive care stay, and worse clinical outcomes.1Jetton J.G. Boohaker L.J. Sethi S.K. et al.Incidence and outcomes of neonatal acute kidney injury (AWAKEN): a multicentre, multinational, observational cohort study.Lancet Child Adolesc Health. 2017; 1: 184-194https://doi.org/10.1016/S2352-4642(17)30069-XAbstract Full Text Full Text PDF PubMed Scopus (272) Google Scholar,2Agrawal G. Wazir S. Sethi S.K. et al.Incidence, risk factors, and outcomes of neonatal acute kidney injury: protocol of a multicentric prospective cohort study [the Indian iconic neonatal kidney educational registry].Front Pediatr. 2021; 9: 690559https://doi.org/10.3389/fped.2021.690559Crossref PubMed Scopus (4) Google Scholar In order to mitigate the avoidable outcomes, it is important to identify AKI early and start early therapeutic measures.2Agrawal G. Wazir S. Sethi S.K. et al.Incidence, risk factors, and outcomes of neonatal acute kidney injury: protocol of a multicentric prospective cohort study [the Indian iconic neonatal kidney educational registry].Front Pediatr. 2021; 9: 690559https://doi.org/10.3389/fped.2021.690559Crossref PubMed Scopus (4) Google Scholar,3Charlton J.R. Boohaker L. Askenazi D. et al.Incidence and risk factors of early onset neonatal AKI.Clin J Am Soc Nephrol. 2019; 14: 184-195https://doi.org/10.2215/CJN.03670318Crossref PubMed Scopus (50) Google Scholar There have been previous attempts to derive illness severity scores, such as the Clinical Risk Index for Babies, the Simplified age-weight-sex score, Pediatric Risk of Mortality and Pediatric Index of Mortality among neonates and children.4Gemke R.J. van Vught J. Scoring systems in pediatric intensive care: PRISM III versus PIM.Intensive Care Med. 2002; 28: 204-207https://doi.org/10.1007/s00134-001-1185-2Crossref PubMed Scopus (78) Google Scholar These scores assess the illness severity, and cannot be used for the risk stratification for AKI or mortality. Risk of mortality in low birth weight neonates has been predicted by the NMR-2000 score, which was validated for use in low to middle income countries.5Medvedev M.M. Brotherton H. Gai A. et al.Development and validation of a simplified score to predict neonatal mortality risk among neonates weighing 2000 g or less (NMR-2000): an analysis using data from the UK and The Gambia.Lancet Child Adolesc Health. 2020; 4: 299-311https://doi.org/10.1016/S2352-4642(20)30021-3Abstract Full Text Full Text PDF PubMed Scopus (17) Google Scholar A specific score for AKI risk stratification in older children, Renal Angina Index, which uses the reduction in estimated creatinine clearance, fluid balance and high-risk disease states, has been shown to predict AKI accurately among various high-risk disease states.6Basu R.K. Zappitelli M. Brunner L. et al.Derivation and validation of the renal angina index to improve the prediction of acute kidney injury in critically ill children.Kidney Int. 2014; 85: 659-667https://doi.org/10.1038/ki.2013.349Abstract Full Text Full Text PDF PubMed Scopus (144) Google Scholar Neonatal AKI risk scores are imperative to help predict which neonates are at a high-risk and should have early directed interventions. The STARZ score predicts the risk of AKI in neonates with high sensitivity (92.8%), specificity (87.4%), positive predictive value (80.5%), negative predictive value (95.6 %,) and accuracy (89.4%), which allows for its validation for use in low to middle income countries to facilitate the rapid identification of at-risk neonates.7Wazir S. Sethi S.K. Agarwal G. et al.Neonatal acute kidney injury risk stratification score: STARZ study.Pediatr Res. 2021; 91: 1141-1148https://doi.org/10.1038/s41390-021-01573-9Crossref PubMed Scopus (6) Google Scholar,8Sethi S.K. Raina R. Rana A. et al.Validation of the STARZ neonatal acute kidney injury risk stratification score.Pediatr Nephrol. 2022; 37: 1923-1932https://doi.org/10.1007/s00467-021-05369-1Crossref PubMed Scopus (2) Google Scholar The variables of the STARZ score are shown in Table 1. This research letter reports cut-off scores required for identifying risk of severe AKI and dialysis need in neonates. The methodology and statistical analysis of the study is provided in the Supplementary Material.Table 1STARZ scoring modelVariablesAssigned scoreAge at entry in NICU (hs)<25.56≥25.50PPV in the delivery roomYes7No0Gestational age (wks)<287≥280Sepsis (during the NICU stay)Yes6No0Significant cardiac diseaseYes10No0Urine outputaFirst 12 hours post admission in NICU. (ml/kg/h)<1.327≥1.320Serum creatinineaFirst 12 hours post admission in NICU. (mg/dl)≥0.9820<0.980Use of nephrotoxic drugsYes11No0Use of furosemideYes9No0Use of inotropesYes17No0AKI, acute kidney disease; NICU, neonatal intensive care unit; PPV, positive pressure ventilation.Nephrotoxic drugs included Vancomycin or Colistin or Amphotericin BSignificant cardiac disease included hemodynamically significant patent ductus arteriosus, persistent pulmonary hypertension of the newborn, cardiogenic shock and other congenital heart diseaseInotropes included Dopamine or Dobutamine or Epinephrine or Norepinephrinea First 12 hours post admission in NICU. Open table in a new tab ResultsThe current study included 1005 neonates (646 without AKI and 359 with AKI) that met the inclusion criteria. The flow of the study is shown in Supplementary Figure S1. Of the 359 neonates with AKI, 58 (16.2%) had stage 1 AKI, 77 (21.4%) had stage 2 AKI, and 224 (62.4%) had stage 3 AKI. The neonates with gestational age at birth less than 28 weeks were 34 (3.4%), those who required positive pressure ventilation in delivery room were 189 (18.8%), those who were aged less than 25.5 hours at entry in neonatal intensive care unit (NICU) were 580 (57.7%), those who had sepsis during NICU stay were 684 (68.1%), and those with significant cardiac disease were 288 (28.7%). Neonates whose serum creatinine was greater than or equal to 0.98 mg/dl were 314 (31.2%), those with urine output less than 1.32 ml/kg/h were 512 (50.9%), those with nephrotoxic drug use were 920 (91.5%), those with furosemide use 44 (4.4%), and those with inotrope use were 388 (38.6%). A total of 52 (5.2%) neonates died during NICU stay. The median (interquartile range [IQR]) STARZ score was 34 (23–57) and length of NICU stay was 10 (5–18) days (Supplementary Table S1).The comparison of different variables among neonates with severe AKI (AKI stage 3) versus mild to moderate AKI (AKI stages 1–2) is presented in Table 2. Comparing these 2 groups of neonates, respectively, the proportion with significant cardiac disease (107 [47.8%] vs. 39 [28.9%], P < 0.001), inotropes usage (162 [72.3%] vs. 82 [60.7%], P = 0.027), and those with serum creatinine greater than or equal to 0.98 mg/dl (223 [99.6%] vs. 71 [52.6%], P < 0.001) were significantly higher among those with severe AKI than among those mild to moderate AKI. The median (IQR) STARZ score was found to be significantly higher (67 [54–77] vs. 50 [40–61]. P < 0.001) among neonates with severe AKI than among those with mild to moderate AKI. The best cut-off value STARZ score for severe AKI was found to be 59 with a sensitivity of 71% and specificity of 70% and with an area under the receiver operating characteristic curve of 0.755 (95% CI: 0.704 – 0.806, P < 0.001) (Figure 1). The median (IQR) time to AKI was observed to be significantly lower (1 [1–3] vs. 3 [1–3] days, P < 0.001) among neonates with severe AKI than among those with mild to moderate AKI.Table 2Comparison of different variables among neonates without AKI versus stage 1 AKI versus stage 2 AKI versus stage 3 AKIVariablesNo AKI (n = 646)Stage 1 (n = 58)Stage 2 (n = 77)Stage 3 (n = 224)P valueMaternal antenatal characteristics [Y]184 (28.5%)22 (37.9%)36 (46.8%)100 (44.6%)<0.001Severe peripartum event [Y]7 (1.1%)1 (1.7%)2 (2.6%)4 (1.8%)0.386Site of delivery (Outborn)254 (39.3%)24 (41.4%)32 (41.6%)118 (52.7%)0.007Mode of delivery (Cesarean)377 (58.4%)39 (67.2%)52 (67.5%)120 (53.6%)0.084Gender (Male)446 (69%)42 (72.4%)54 (70.1%)155 (69.2%)0.967Gestational age birth (<28 wks)15 (2.3%)0 (0%)6 (7.8%)13 (5.8%)0.005Birth weight (<1000 gm)17 (2.6%)0 (0%)5 (6.5%)21 (9.4%)<0.001PPV in delivery room [Y]91 (14.1%)11 (19%)21 (27.3%)66 (29.5%)<0.001Age at NICU entry (<25.5 hs)328 (50.8%)42 (72.4%)51 (66.2%)159 (71%)<0.001APGAR score at 5 minsaReported as median (IQR); for others as proportion8 (7–8)8 (7–8)7 (6–8)7 (6–8)<0.001Respiratory support in NICU414 (64.1%)50 (86.2%)69 (89.6%)195 (87.1%)<0.001Sepsis during the NICU stay [Y]379 (58.7%)40 (69%)71 (92.2%)194 (86.6%)<0.001Significant cardiac disease142 (22%)15 (25.9%)24 (31.2%)107 (47.8%)<0.001Necrotizing enterocolitis [Y]16 (2.5%)2 (3.4%)5 (6.5%)16 (7.1%)0.008Intraventricular hemorrhage [Y]21 (3.3%)3 (5.2%)8 (10.4%)17 (7.6%)0.005Any surgical intervention [Y]32 (5%)3 (5.2%)4 (5.2%)16 (7.1%)0.65Evidence of fluid overloadbFirst 12 hours post admission in NICU [Y]7 (1.1%)0 (0%)1 (1.3%)6 (2.7%)0.27Multiple seizurebFirst 12 hours post admission in NICU [Y]55 (8.5%)7 (12.1%)6 (7.8%)46 (20.5%)<0.001Nephrotoxic drug [Y]564 (87.3%)57 (98.3%)77 (100%)222 (99.1%)<0.001Furosemide [Y]23 (3.6%)1 (1.7%)4 (5.2%)16 (7.1%)0.111Caffeine [Y]111 (17.2%)6 (10.3%)23 (29.9%)62 (27.7%)<0.001Inotropic drugs [Y]144 (22.3%)29 (50%)53 (68.8%)162 (72.3%)<0.001Mean arterial pressureaReported as median (IQR); for others as proportion,bFirst 12 hours post admission in NICU51 (44–67)49 (43–56)46 (42–57)46 (41–54)<0.001IV fluid intake (ml/kg/d)aReported as median (IQR); for others as proportion,bFirst 12 hours post admission in NICU60 (60–68)60 (60–69)60 (60–65)60 (60–70)0.184Creatinine ≥0.98 mg/dl [Y]20 (3.1%)33 (56.9%)38 (49.4%)223 (99.6%)<0.001Urine output <1.32 ml/kg/hr [Y]292 (45.2%)32 (55.2%)45 (58.4%)143 (63.8%)<0.001Serum urea (mg/dl)aReported as median (IQR); for others as proportion,bFirst 12 hours post admission in NICU20 (17–24)38 (32–42)28 (23–38)42 (35–53)<0.001Serum sodium (meq/l)aReported as median (IQR); for others as proportion,bFirst 12 hours post admission in NICU133 (132–138)138 (134–142)135 (130–139)135 (132–139)<0.001Serum potassium(meq/l)aReported as median (IQR); for others as proportion,bFirst 12 hours post admission in NICU4.5 (4.2–4.7)5.2 (5–5.4)4.8 (4.7–5.2)5.3 (5–5.5)<0.001Hb (g/l)aReported as median (IQR); for others as proportion,bFirst 12 hours post admission in NICU16.5 (15.4–18.4)17 (15.8–19)17.2 (16–18.2)16.2 (14.7–17.5)0.016Serum pHaReported as median (IQR); for others as proportion,bFirst 12 hours post admission in NICU7.32 (7.28–7.32)7.32 (7.25–7.41)7.29 (7.28–7.32)7.26 (7.2–7.32)<0.001STARZ scoreaReported as median (IQR); for others as proportion24 (17–34)47 (37–60)50 (43–65)67 (54–77)<0.001No. of days to AKIaReported as median (IQR); for others as proportion-3 (2–7)3 (1–3)1 (1–3)<0.001NICU stay (ds)aReported as median (IQR); for others as proportion8 (4.75–15.25)10 (6–17.25)18 (9–30.75)11 (5–22)<0.001Death10 (1.5%)1 (1.7%)2 (2.6%)39 (17.4%)<0.001AKI, acute kidney injury; Hb, hemoglobin; IV, Intravenous; IQR, interquartile range; NICU, neonatal intensive care unit; PPV, positive pressure ventilation; Y, yes.Nephrotoxic drugs included Vancomycin or Colistin or Amphotericin BInotropes included Dopamine or Dobutamine or Epinephrine or NorepinephrineSignificant cardiac disease included patent ductus arteriosus, pulmonary hypertension of the newborn, ventricular septal defect; shockSevere peripartum event included cord prolapsed, precipitate labor, abruptionMultiple seizures were defined as >1 seizure episode in the first 12 hFluid overload defined as >10% during the first 12 h post admissionEven a single exposure of the drug has been considered as usage of drugMaternal characteristics recorded were- maternal diabetes, maternal pregnancy induced hypertension, maternal bacterial/ viral infections/ IUGR/ oligohydramnios/ polyhydramnios/ use of drugs during pregnancy (ACE-inhibitors, NSAIDs, tobacco, alcohol, antidepressants, steroids)a Reported as median (IQR); for others as proportionb First 12 hours post admission in NICU Open table in a new tab The comparison of different variables among stage 3 AKI neonates treated with peritoneal dialysis (PD) versus those treated without PD is presented in Supplementary Table S2. The proportion of neonates with gestational age at birth less than 28 weeks (5 [14.7%] vs. 8 [4.2%], P = 0.031], with significant cardiac disease (28 [82.4%] vs. 79 [41.6%], P < 0.001), with furosemide usage (6 [17.6%] vs. 10 [5.3%], P = 0.02), with inotropes usage (33 [97.1%] vs. 129 [67.9%], P < 0.001], and with urine output less than 1.32 ml/kg/h (30 [88.2%] vs. 113 [59.5%], P = 0.001) were significantly higher among those with severe AKI than among those with mild to moderate AKI. As expected, the median (IQR) STARZ score was observed to be significantly higher (77 [71–84] vs. 64 [50 – 77], P < 0.001) among stage 3 AKI neonates treated with PD than among those treated without PD. The best cut-off value STARZ score was found to be 66 with a sensitivity of 97% and specificity of 52% for PD use with an area under the receiver operating characteristic curve of 0.804 (95% CI: 0.738 –0.870), P < 0.001) (Supplementary Figure S2). The median (IQR) time to AKI was observed to be significantly lower (1 [1–2] vs. 1 [1–3] days, P = 0.017) among stage 3 AKI neonates treated with PD than among those treated without PD.Mortality was observed to be significantly higher among those with severe AKI than among those with mild to moderate AKI (39 [17.4%] vs. 3 [2.2%], odds ratio [95% CI]: 9.28 [2.81–30.65]), and significantly higher among stage 3 AKI neonates treated with PD than among those treated without PD (30 [88.2%] vs. 9 [4.7%], 150.83 [43.67–521.0). Nevertheless, the median (IQR) duration of stay in the NICU was significantly lower among those with severe AKI than among those with mild to moderate AKI (11 [5–22] vs. 14 [7–25] days. P = 0.033); and significantly lower among stage 3 AKI neonates treated with PD than among those treated without PD (7 [3–11] vs. 12 [6–23] days. P = 0.001) (Table 2 and Supplementary Table S2).To summarize, we found the following cut-offs for neonatal AKI prediction: STARZ score less than 31.5 predicts low probability of AKI; STARZ score less than 59 predicts low probability of severe AKI, and STARZ score less than 66 predicts low probability of severe AKI with the need for PD. The cut-off scores were found to increase with increased AKI severity. Similar studies to derive cut-offs to predict severe AKI and need for dialysis have been done with urine neutrophil gelatinase-associated lipocalin at admission in adults.9Albert C. Zapf A. Haase M. et al.Neutrophil gelatinase-associated lipocalin measured on Clinical Laboratory platforms for the prediction of acute kidney injury and the associated need for dialysis therapy: a systematic review and meta-analysis.Am J Kidney Dis. 2020; 76: 826-841.e1https://doi.org/10.1053/j.ajkd.2020.05.015Abstract Full Text Full Text PDF PubMed Scopus (38) Google Scholar To our knowledge, this is the first of its kind study to use a scoring system that can easily be replicated in NICU. Nevertheless, further studies are needed to validate the cut-off scores. These cut-offs can help a clinician to determine the need for dialysis requirement, anticipate severe neonatal AKI and acts as a beneficial and easy clinical adjunct to neonatal intensive care units of all types.DisclosureAll the authors declared no competing interests.Author ContributionsAll authors made substantial contributions to conception and design, acquisition of data, analysis and interpretation of data; drafting the article or revising it critically for important intellectual content. All authors gave final approval of the version to be published. IntroductionNeonatal acute kidney injury (AKI) is a significant pathology associated with higher mortality rates, longer neonatal intensive care stay, and worse clinical outcomes.1Jetton J.G. Boohaker L.J. Sethi S.K. et al.Incidence and outcomes of neonatal acute kidney injury (AWAKEN): a multicentre, multinational, observational cohort study.Lancet Child Adolesc Health. 2017; 1: 184-194https://doi.org/10.1016/S2352-4642(17)30069-XAbstract Full Text Full Text PDF PubMed Scopus (272) Google Scholar,2Agrawal G. Wazir S. Sethi S.K. et al.Incidence, risk factors, and outcomes of neonatal acute kidney injury: protocol of a multicentric prospective cohort study [the Indian iconic neonatal kidney educational registry].Front Pediatr. 2021; 9: 690559https://doi.org/10.3389/fped.2021.690559Crossref PubMed Scopus (4) Google Scholar In order to mitigate the avoidable outcomes, it is important to identify AKI early and start early therapeutic measures.2Agrawal G. Wazir S. Sethi S.K. et al.Incidence, risk factors, and outcomes of neonatal acute kidney injury: protocol of a multicentric prospective cohort study [the Indian iconic neonatal kidney educational registry].Front Pediatr. 2021; 9: 690559https://doi.org/10.3389/fped.2021.690559Crossref PubMed Scopus (4) Google Scholar,3Charlton J.R. Boohaker L. Askenazi D. et al.Incidence and risk factors of early onset neonatal AKI.Clin J Am Soc Nephrol. 2019; 14: 184-195https://doi.org/10.2215/CJN.03670318Crossref PubMed Scopus (50) Google Scholar There have been previous attempts to derive illness severity scores, such as the Clinical Risk Index for Babies, the Simplified age-weight-sex score, Pediatric Risk of Mortality and Pediatric Index of Mortality among neonates and children.4Gemke R.J. van Vught J. Scoring systems in pediatric intensive care: PRISM III versus PIM.Intensive Care Med. 2002; 28: 204-207https://doi.org/10.1007/s00134-001-1185-2Crossref PubMed Scopus (78) Google Scholar These scores assess the illness severity, and cannot be used for the risk stratification for AKI or mortality. Risk of mortality in low birth weight neonates has been predicted by the NMR-2000 score, which was validated for use in low to middle income countries.5Medvedev M.M. Brotherton H. Gai A. et al.Development and validation of a simplified score to predict neonatal mortality risk among neonates weighing 2000 g or less (NMR-2000): an analysis using data from the UK and The Gambia.Lancet Child Adolesc Health. 2020; 4: 299-311https://doi.org/10.1016/S2352-4642(20)30021-3Abstract Full Text Full Text PDF PubMed Scopus (17) Google Scholar A specific score for AKI risk stratification in older children, Renal Angina Index, which uses the reduction in estimated creatinine clearance, fluid balance and high-risk disease states, has been shown to predict AKI accurately among various high-risk disease states.6Basu R.K. Zappitelli M. Brunner L. et al.Derivation and validation of the renal angina index to improve the prediction of acute kidney injury in critically ill children.Kidney Int. 2014; 85: 659-667https://doi.org/10.1038/ki.2013.349Abstract Full Text Full Text PDF PubMed Scopus (144) Google Scholar Neonatal AKI risk scores are imperative to help predict which neonates are at a high-risk and should have early directed interventions. The STARZ score predicts the risk of AKI in neonates with high sensitivity (92.8%), specificity (87.4%), positive predictive value (80.5%), negative predictive value (95.6 %,) and accuracy (89.4%), which allows for its validation for use in low to middle income countries to facilitate the rapid identification of at-risk neonates.7Wazir S. Sethi S.K. Agarwal G. et al.Neonatal acute kidney injury risk stratification score: STARZ study.Pediatr Res. 2021; 91: 1141-1148https://doi.org/10.1038/s41390-021-01573-9Crossref PubMed Scopus (6) Google Scholar,8Sethi S.K. Raina R. Rana A. et al.Validation of the STARZ neonatal acute kidney injury risk stratification score.Pediatr Nephrol. 2022; 37: 1923-1932https://doi.org/10.1007/s00467-021-05369-1Crossref PubMed Scopus (2) Google Scholar The variables of the STARZ score are shown in Table 1. This research letter reports cut-off scores required for identifying risk of severe AKI and dialysis need in neonates. The methodology and statistical analysis of the study is provided in the Supplementary Material.Table 1STARZ scoring modelVariablesAssigned scoreAge at entry in NICU (hs)<25.56≥25.50PPV in the delivery roomYes7No0Gestational age (wks)<287≥280Sepsis (during the NICU stay)Yes6No0Significant cardiac diseaseYes10No0Urine outputaFirst 12 hours post admission in NICU. (ml/kg/h)<1.327≥1.320Serum creatinineaFirst 12 hours post admission in NICU. (mg/dl)≥0.9820<0.980Use of nephrotoxic drugsYes11No0Use of furosemideYes9No0Use of inotropesYes17No0AKI, acute kidney disease; NICU, neonatal intensive care unit; PPV, positive pressure ventilation.Nephrotoxic drugs included Vancomycin or Colistin or Amphotericin BSignificant cardiac disease included hemodynamically significant patent ductus arteriosus, persistent pulmonary hypertension of the newborn, cardiogenic shock and other congenital heart diseaseInotropes included Dopamine or Dobutamine or Epinephrine or Norepinephrinea First 12 hours post admission in NICU. Open table in a new tab
Risk factors and outcomes of neonates with acute kidney injury needing peritoneal dialysis: Results from the prospective TINKER (The Indian PCRRT-ICONIC Neonatal Kidney Educational Registry) study Sidharth Kumar Sethi, Sanjay Wazir, Jagdish Sahoo, Gopal Agrawal, Naveen Bajaj, Naveen Parkash Gupta, Shishir Mirgunde, Binesh Balachandran, Kamran Afzal, Anubha Shrivastava, Jyoti Bagla, Sushma Krishnegowda, Ananth Konapur, Azmeri Sultana, Kritika Soni, Nikhil Nair, Divya Sharma, Prajit Khooblall, Avisha Pandey, Khalid Alhasan, Mignon McCulloch, Timothy Bunchman, Abhishek Tibrewal, Rupesh Raina Peritoneal Dialysis International, 2022 Background: Acute kidney injury (AKI) is common in neonates admitted to neonatal intensive care units (NICUs). There is a need to have prospective data on the risk factors and outcomes of acute peritoneal dialysis (PD) in neonates. The use of kidney replacement therapy in this population compared to older populations has been associated with worse outcomes (mortality rates 17–24%) along with a longer stay in the NICU and/or hospital. Methods: The following multicentre, prospective study was derived from the TINKER (The Indian PCRRT-ICONIC Neonatal Kidney Educational Registry) database, assessing all admitted neonates ≤28 days who received intravenous fluids for at least 48 h. The following neonates were excluded: death within 48 h, presence of any lethal chromosomal anomaly, requirement of congenital heart surgery within the first 7 days of life and those receiving only routine care in nursery. Demographic data (maternal and neonatal) and daily clinical and laboratory parameters were recorded. AKI was defined according to the Neonatal Kidney Disease: Improving Global Outcomes criteria. Results: Of the included 1600 neonates, a total of 491 (30.7%) had AKI. Of these 491 neonates with AKI, 44 (9%) required PD. Among neonates with AKI, the odds of needing PD was significantly higher among those with significant cardiac disease (odds ratio (95% confidence interval): 4.95 (2.39–10.27); p < 0.001), inotropes usage (4.77 (1.98–11.51); p < 0.001), severe peripartum event (4.37 (1.31–14.57); p = 0.02), requirement of respiratory support in NICU (4.17 (1.00–17.59); p = 0.04), necrotising enterocolitis (3.96 (1.21–13.02); p = 0.03), any grade of intraventricular haemorrhage (3.71 (1.63–8.45); p = 0.001), evidence of fluid overload during the first 12 h in NICU (3.69 (1.27–10.70); p = 0.02) and requirement of resuscitation in the delivery room (2.72 (1.45–5.12); p = 0.001). AKI neonates with PD as compared to those without PD had a significantly lower median (interquartile range) duration of stay in NICU (7 (4–14) vs. 11 (6–21) days; p = 0.004), but significantly higher mortality (31 (70.5%) vs. 50 (3.2%); p < 0.001). This discrepancy is likely attributable to the critical state of the neonates with AKI. Conclusions: This is the largest prospective, multicentre study specifically looking at neonatal AKI and need for dialysis in neonates. AKI was seen in 30.7% of neonates (with the need for acute PD in 9% of the AKI group). The odds of needing acute PD were significantly higher among those with significant cardiac disease, inotropes usage, severe peripartum event, requirement of respiratory support in NICU, necrotising enterocolitis, any grade of intraventricular haemorrhage, evidence of fluid overload more than 10% during the first 12 h in NICU and requirement of resuscitation in the delivery room. AKI neonates with PD as compared to AKI neonates without PD had a significantly higher mortality. There is a need to keep a vigilant watch in neonates with risk factors for the development of AKI and need for PD.
Prevalence of hepatitis B & C infections in prospective blood donors deferred due to history of jaundice Mohd. Fawad Farooq Khan, Kamran Afzal, S. H. Arif, Shadma Shahin Indian Journal of Medical Research, 2022 Background & objectives: As per national guidelines, prospective blood donors with a history of jaundice of unknown cause are deferred permanently to prevent the transmission of hepatitis B and C. The validity of this guideline was tested by comparing prevalence rates of hepatitis B and C in prospective blood donors deferred due to a history of jaundice, with that of donors who were found fit. Methods: Blood samples of 212 consecutive donors (male, n=203) deferred due to a history of jaundice were studied for hepatitis B and C by rapid test kits as well as by chemiluminescence (n=115) or ELISA (n=97). Consecutive healthy donors (n=549; male, n=518) were also studied by ELISA (n=266) or chemiluminescence (n=283). Results: The cumulative prevalence detected by rapid test kit and ELISA/chemiluminescence tests of hepatitis B (n=10) and C (n=2) among donors deferred due to a history of jaundice (n=212) was 5.7 per cent [95% confidence interval (CI): 2.9, 9.9]. The prevalence of reactive results among healthy donors (n=549) by ELISA/chemiluminescence tests was 3.3 per cent (95% CI: 1.9, 5.2), which included hepatitis B (n=15) and hepatitis C (n=3) cases. Compared to healthy donors, the odds of seropositivity among jaundice-deferred donors was 1.7 (95% CI: 0.8, 3.6), P=0.15. For rapid test-negative deferred donors, the odds of seropositivity by ELISA/chemiluminescence declined to 0.4 (0.1, 1.5), P=0.19. Interpretation & conclusions: The prevalence rates of hepatitis B and C in prospective blood donors deferred due to a history of jaundice of unknown aetiology did not differ significantly from that in healthy donors. The current practice of permanently deferring such donors depletes valuable donor pool. A strategy of rejecting only those donors who are found reactive on pre-donation testing by rapid test needs further validation.
Canon CP-TX1 camera - As a screening tool for amblyogenic risk factors Syed Aisha Raza, Abadan Khan Amitava, Yogesh Gupta, Kamran Afzal, Farnaz Kauser, Juhi Saxena, Anam Masood, Aparna Bose, Ramprakash Singh Indian Journal of Ophthalmology, 2022 Purpose: To evaluate the Canon CP-TX1 camera as a screening tool for ARFs in a pediatric population and estimate the prevalence of ARFs. Methods: In a pediatric outpatient space, largely in the immunization clinic, after obtaining parental consent, we encouraged children to be photographed from a distance of 5 feet in a dim room by using a CP-TX1 camera with the red-eye reduction feature off. Based on the captured red reflex, children were labeled as normal (symmetrical red reflexes in the two eyes, with no visible crescents); all others were considered as abnormal or positive for ARFs. All photographed children were assessed by an optometrist/refractionist for VA by age-appropriate methods. Data were entered into a 2 × 2 contingency table on statpages.org, and diagnostic indices were calculated with 95%CI. Results: With a sample of 262 children, we obtained a sensitivity of 0.82, a specificity of 0.98, a positive predictive value of 0.92, a negative predictive value of 0.94, a positive likelihood ratio of 41.06, a negative likelihood ratio of 0.17, and a prevalence of 0.24 for ARFs Conclusion: CP-TX1 performed well as a screening tool to identify ARFs in children. Placing such a camera in an immunization clinic offers a chance to identify children with ARFs at a time when amblyopia is eminently reversible.
Validation of the STARZ neonatal acute kidney injury risk stratification score in an independent prospective cohort Gurdeep Singh Dhooria, Arushi Nautiyal, Sanjay Wazir, Gopal Agrawal, Anupreet Tiwana, Naveen Bajaj, Naveen Parkash Gupta, Shishir Mirgunde, Jagdish Sahoo, Binesh Balachandran, Kamran Afzal, Anubha Shrivastava, Jyoti Bagla, Sushma Krishnegowda, Ananth Konapur, Kritika Soni, Mignon McCulloch, Timothy Bunchman, Sidharth Kumar Sethi, Rupesh Raina Journal of Neonatal Perinatal Medicine, 2022 OBJECTIVE: A rapid AKI risk assessment score would allow for improving management and outcomes. STARZ (Sethi, Tibrewal, Agrawal, Raina, waZir) score was developed for acute kidney injury (AKI) risk stratification of critically ill neonates. This is the first independent validation for the novel score outside the original enrolled centres. STUDY DESIGN: 750 neonates were included in the study. The STARZ score was calculated after 12 hours of admission. Neonates admitted in NICU and receiving IV fluids for at least 48 hours were included. RESULTS: A total of 8.8% neonates had AKI in the first 7 days post admission. The duration of hospital stay was significantly higher among neonates with AKI [10.5 (7–19) vs. 7 (5–10) days; p < 0.001]. Mortality risk was 6.4 times higher among those with AKI [8 (12.1%) vs. 13 (1.9%); p < 0.001; RR (95% CI): 6.38 (2.74–14.83)]. In this study, the STARZ neonatal scoring model showed a sensitivity of 89.4% in detecting AKI with a 90.9% specificity and a high negative predictive value of 98.9%. The area under ROC was 0.958 (0.934–0981) - a high discriminative power. CONCLUSIONS: The STARZ score allows for AKI risk stratification, providing opportunity for therapeutic interventions which may improve outcomes in critically ill neonates.
Pediatric psychosis in the emergency room: Could it be Plasmodium vivax malaria? Current Pediatric Research, 2016
Reduced Volume Isotonic Saline as Maintenance Fluids in Children: Authors reply Indian Pediatrics, 2015
Correspondence Prasad Krishnan, Birendra Rai, Farhana Sharif, Ruchi Rai, D. K. Singh, Shambhawi Roy, Aashima Dabas, Sonali Mitra, Rakesh Mondal, Abdul Razak, N. Karthik Nagesh, Wei Zhang, Zonghong Shao, Tanigasalam Vasanthan, C. Venkatesh, Abdul Razak, Ahmar Shamim, Kamran Afzal, T. Jacob John, C. E. Eapen Indian Pediatrics, 2015
